Does medicare pay for Nursing Home? (Maybe!)

The video explains Medicare’s coverage for skilled nursing facilities, highlighting the differences between Original Medicare and Medicare Advantage plans regarding rehab services.

Highlights

1. Coverage Breakdown: Medicare covers 20 days in skilled nursing facilities at no cost, with a copayment for days 21-100.
2. Inpatient Requirement: A minimum of three days of inpatient hospital admission is required to qualify for skilled nursing care.
3. Advantage Plan Issues: Medicare Advantage plans can deny coverage decisions made by doctors, giving insurers the power over patient care.
4. Appeals Stress: Many patients face a complicated appeals process while in recovery, adding extra stress during their medical crisis.
5. Switching Plans: Patients can return to Original Medicare during open enrollment, but may struggle to find a suitable supplement plan due to health issues.

Keywords

Medicare, nursing home, skilled care, Advantage plans, coverage eligibility.so it’s important to understand the benefits from Medicare for Skilled Nursing Facility certainly before you end up in a Skilled Nursing Facility you need to understand what your coverage is so you know how things are going to be handled and we don’t have any surprises and obviously if we’re headed to a Skilled Nursing Facility we don’t want any surprises so when we’re talking about skilled nursing care with Medicare we’re not talking about long-term care we’re talking about rehab

00:27

so where you would go if you say had a stroke or if you had hip replacement or something where you needed Rehabilitation to gain Improvement before you go back home so it’s really important to understand because there are two completely different ways that this can be handled within Medicare and the main differences are whether you’re on original Medicare with a Medicare Supplement Plan or whether you have chosen to go with a Medicare Advantage plan so we need to understand what we need to know before we get there

01:00

so first thing to understand is the coverage so Medicare covers the first 20 days in a skilled nursing facility at no cost so there’s no co-pays no coinsurance covered under part A from day 21 to 100 they also cover but there’s a 200 copay that goes along with it obviously a significant amount of money now the good side of that a Medicare supplement or a Medicare Advantage plan usually covers that out of pocket expense so pretty much there can be up to 100 days of coverage in a Skilled Nursing Facility now keep in

01:36

mind in order to qualify for skilled nursing care there’s other parameters so what needs to happen is you need to have at least three days inpatient hospital admission to qualify for skilled nursing care now this can get a little crazy and a little gray and I’ve seen it happen many times when you’re in the hospital you could be there a day or two days or three days and you certainly think it’s impatient because you’re there you’re staying the night but hospitals can classify it as observation as opposed to

02:07

inpatient and I really don’t have the answers to why they do it as observation because it doesn’t make a lot of sense but if it is observation you wouldn’t qualify for skilled nursing care or rehab after the hospital state it has to be inpatient hospital admission three days or more and then you get discharged to a skilled nursing facility for Rehab again after a stroke after a hip replacement surgery knee replacement surgery something significant where obviously you can’t just go home you need rehab to be able

02:39

to get back to where you can take care of yourself so here’s where we reached the problem with original Medicare with a Medicare Supplement Plan generally it’s not a problem generally the doctor makes the decision if you need to stay you’re going to stay and they’re going to pay Medicare Advantage is different where the decision lies not with the doctor but with the medical plan they make the determination on whether or not you’re going to be able to say whether or not they’re going to pay for you to

03:10

stay in a Skilled Nursing Facility so I’m gonna go through an article here that’s in the Kaiser Family Foundation they published it very creditable third party no obligation group that covers a lot of senior stuff and Medicare stuff and this article gives the breakdown on how things work and how they differ so we start here after 11 days in a St Paul Minnesota Skilled Nursing Facility recuperating from a fall Paula Christopherson 97 so she fell she was in the hospital for a number of days released to a Skilled Nursing Facility

03:44

as anyone would expect well was told by her and sure that she should return home but instead of being relieved Christopherson and her daughter were worried because medical team said she wasn’t well enough to leave this seems unethical said her daughter who feared what would happen if the Medicare Advantage plan run by United Healthcare ended coverage for her mother’s nursing home care the facility gave Christopherson a choice pay several thousand dollars to stay appeal the company’s decision or go home

04:17

you don’t want to be in that position at 97 where you just are recuperating from a fall and those are your choices on what you can do to continue your medical care so it’s certainly a scenario that makes things very difficult the article goes on to say half of nearly 65 million people with Medicare are enrolled in Private health plans called Medicare Advantage an alternative to the traditional Medicare program the plans must cover at a minimum the same benefits as traditional Medicare including up to 100 days of skilled

04:51

nursing home care every year but the private plans have leeway deciding how much nursing home care a patient needs in traditional Medicare the medical professionals at the facility decide when someone is safe to go home said Eric Krupa an attorney at the center for Medicare advocacy a non-profit Law Group that advises beneficiaries in Medicare Advantage the plan decides so it’s super important to understand that that you are not guaranteed your benefit days at a Skilled Nursing Facility if you are on a Medicare Advantage plan so you want to

05:29

be well aware of that for sure on how it’s going to be handled my repainter a vice president National Association of State long-term care Omni bugsman program who directs Connecticut’s office said people are going to the nursing home and then very quickly getting denied and then told to appeal which adds to their stress when they’re already trying to recuperate so that’s crazy that you have to appeal while you’re in medical crisis at a nursing home in order to be able to stay at the nursing home so it’s it’s

06:06

certainly complicated and makes things much more difficult than they need to be the problem has become more widespread and more frequent said Dr Rajiv Kumar vice president Society of Post Acute Long-Term Care Medicine which represents long-term care practitioners it’s not just one plan it’s pretty much all that so this appeals process just how much does a person want to fight is where it comes down to where we’re probably going to cover it but you’re going to have to put up a fight if you want us to cover

06:39

it and we’re hoping that you’re really not going to put up that much of a fight so they play the odds and then that’s kind of how it works which is it’s really unfortunate and I’ve had just too many calls from people that have had a husband or a wife or a sibling or a friend in a nursing home that is being told that they have to go home and they’re not ready to go home and they want to know how to get off the Medicare Advantage plan and get back to original Medicare and in Most states you can if you’re in

07:09

a health situation you won’t be able to you can come back to original Medicare during an open enrollment period also another time locked scenario but you likely wouldn’t be able to get a Medicare Supplement Plan because of a health situation one other quick story Patricia Maynard 80 a retired Connecticut school cafeteria employee was in a nursing home recovering from a hip replacement and believe me hip replacement is almost common practice these days if you make it through life without a hip replacement you’re

07:38

fortunate you’re you’re well above the odds they have become very commonplace and obviously after a hip replacement you’re not going to jump up go walking and get in your car and drive home you’re going to need rehab to be able to get back on your feet and do the things that you’re supposed to do so hers was in December when her I don’t know why they keep using United Healthcare as an example but they do plan notified her it was ending coverage and her doctors disagreed with the decision if I stayed I would have to pay

08:07

or I could go home and not worry about the bill the average daily cost of a semi-private room that’s with a roommate is 415 dollars a day according to a state survey but going home was also impractical I couldn’t walk because of the pain so mayor to peeled the company and the company reversed the decision but a few days later she received another notice saying that they’ve decided to stop payment again over the objections of her medical team the cycle continued 10 times so she had to appeal 10 times and each time they said okay

08:44

you’re okay and then they denied it again and again this is not a rare occasion this is a pretty common occasion if you know anybody that works in a nursing home just ask them how it’s handled under that type of situation and I spoke with somebody that worked in a nursing home and they said what they have to do is every day fill out a form on why the person needs to stay and the Medicare Advantage Representative makes a determination on whether or not they agree and if they don’t agree they don’t pay and then it’s on the

09:17

patient to figure out what they’re going to do from there on original Medicare with the supplement it’s almost reverse where they might keep them there too long because they want to continue to Bill Medicare which is also not a great scenario but likely better to have over coverage than certainly under coverage but that is how things function and if you if you’ve had any experience with it please leave a comment in the video below help others understand that this is how things work in skilled nursing

09:48

care so first off you have to qualify you have to have three days of inpatient hospital admission so observation doesn’t count has to be inpatient and then difference between being on original Medicare with a supplement where it’s pretty much what the doctors say now you can make the decision yourself to go home if you’re ready to go home and they’re saying no we want to stay a little longer because we’re getting paid for you to be here that’s certainly a a case as to where it can happen but you can always make the

10:17

decision where you’re ready to go home Medicare Advantage they’re going to make the decision on whether you’re ready to go home or not so kind of crazy on how that functions but that’s a big reason that I just don’t offer Medicare Advantage because I don’t want this type of situation to come back to me and say why did you set us up with this kind of plan where my spouse or sibling or loved one whatever it may be is now in Jeopardy because they’re being booted out of a Skilled Nursing Facility so I

10:50

hope you understand how this works I hope you find it helpful and we’ll show you right now how to download my book have a fantastic day thank you for taking the time to watch my video hope you found it very helpful a couple of other things that you’ll also find very helpful number one download a copy of my free book Medicare made clear I spent a lot of time and a lot of effort putting this together and it has everything that you need for Medicare now and in the future down the road I have videos in the book I have all the links that you

11:19

need for things that you’ll want to do within Medicare you can access it right in the book very easy to do just visit medicareonvideo.com forward slash free book and you can download it for free you can save it on your computer you can save it on your iPad it’s great resource to have again for now and in the future another thing that you’ll find helpful is down the road when you come into Medicare sometimes it makes sense to do a price check on your Medicare Supplement Plan so I made it very easy

11:49

to do that as well just visit Medicare pricecheck.com put in your basic information and we’ll email you look quote on your same plan that you have right now A G or an N or an F whatever it may be and likely we’ll be able to save twenty to sixty dollars a month in premium because a lot of times plans come out with better rates so if we can get a better rate for the same plan that we currently have just makes a lot of sense and then obviously take advantage of all the information on my website at medicareonvideo.com I have everything

12:23

that you need right there for understanding Irma understanding employer work coverage everything that you need especially in the guides and forms section you’ll find right there so we update everything every year so everything should be up to date and current with the right deductibles and premiums and things like that hope you found all this helpful have a fantastic day wait don’t go anywhere there’s a couple more videos right here that you’ll find very helpful with your Medicare Journey so take just a minute